[Question #4151] Post pep testing and mucocutaneous contact

31 months ago
Hello Dr. On this forum and others, I've read there have never been documented cases of HIV transmission through contact of vaginal fluids from hand to penis mucousa, or from mouth to penis if the woman licked fingers then  spat vaginal fluids on penis to perform a handjob. However i did encounter studies indicating mucocutaneous exposure to HIV from bodily fluids in a healthcare setting. In particular there was a study in the USA documenting five such cases from 1985 to 2013. Understand these are paltry numbers but documented nonetheless. Questions

Since mucocutaneous exposure has happened in a healthcare setting, might it also occur sexually in the manner I described?

Finally, when I finish my 28 day pep course. When is it appropriate to test? My infectious disease Dr says immediately after completion is good. I've heard different timeframes on the net. When is it valuable and when conclusive?
I very much appreciate your valuable insights.
Edward W. Hook M.D.
Edward W. Hook M.D.
31 months ago
I note that this is your 3rd set of, in large part, repetitive questions regarding the virtually no risk events you described and for which you have chosen to take PEP despite the fact that there is very little to no reason to do so.   Repeating your questions is not going to change the answers I provide.  I am unaware to the studies you mention and would be happy to comment on them if you wish to provide a link.  In the interim however, the FACT remains that there are NO documented cases of acquisition of HIV through the mechanisms that you describe.  Of course, perhaps such exposure might sometimes lead to infection in someone -anything can theoretically happen however the FACT is that the risk of your acquiring infection is less than your chance of being struck by lightening (1 in 10,000 in your lifetime) or even your risk of being struck by lightening while reading this reply. 

Most experts feel that testing after completion of PEP should be done at some point after the PEP has been completed and our recommendation is that testing with available combination HIV antigen/antibody tests would be conclusive at 6 weeks after completion of PEP with many infections being detectable sooner. Testing using PCR detection methods would detect PEP failures earlier although precisely how much sooner is not well studied.  My estimate is that a negative pcr at 14 days after completion of PEP would be conclusive.  In the case of your "exposure" as described (partner of unknown HIV status, no known risk exposure), irrespective of when you test I am entirely confident that your test will be negative.  EWH
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31 months ago
Thank you. I am glad you assess my risk to be so low. Please understand there is so much conflicting information on the internet, which is painfully confusing the lay person.
The specific literature I reference in my question is: " Notes from the field: occupationally acquired HIV infection among health care workers - United States, 1985-2013". (PMID:25577991 PMCID:pmc4646046). This was published in morbidity & Mortality Weekly Report, 2015 Jan 9. An excerpt is included below with references made in the article.

The other inconsistency that is baffling to me is the consensus view of survivability/infectivity of the virus outside the body. In our discourse, I understood HIV dies or at least loses infectivity upon contact with the environment outside the body. However, the link below seems to indicate HIV is fairly hearty outside the body:
http://www.aidsmap.com/Survival-outside-the-body/page/1321278/

I would greatly appreciate if you could comment on the following:
1) Does the periodical I provided establish that mucocutaneouos transmission does in fact occur, and particularly in settings where there is not even intimate contact?
2) If mucocutaneous contact does occur, isn't this analogous to my situation where a potentially infectious vaginal fluid was introduced to a mucous membrane?
3) Do you agree with the survivability of the virus outside of the body, or is it irrelevant since it loses infectivity upon contact with air in any case?

I would certainly read any materials/references if you feel they would be helpful to me.

I will follow my dr's advice and test at 28 days and will also the duo test at 6 weeks or a PCR. Thank you very much for clarifying things for me as this is a very confusing time.


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Excerpt:
During 1985–2013, 58 confirmed and 150 possible cases of occupationally acquired HIV infection among HCWs were reported to CDC; since 1999, only one confirmed case (a laboratory technician sustaining a needle puncture while working with a live HIV culture in 2008) has been reported (1; Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, unpublished data, 2014) (Figure). Among the 58 confirmed cases, the routes of exposure resulting in infection were: percutaneous puncture or cut (49 cases), mucocutaneous exposure (five), both percutaneous and mucocutaneous exposure (two), and unknown (two). A total of 49 HCWs were exposed to HIV-infected blood, four to concentrated virus in a laboratory, one to visibly bloody fluid, and four to unspecified body fluids. Occupations of the HCWs with confirmed or possible HIV infection have varied widely (Table).

References
1. Do AN, Ciesielski CA, Metler RP, Hammett TA, Li J, Fleming PL. Occupationally acquired HIV infection: national case surveillance data during 20 years of the HIV epidemic in the United States. Infect Control Hosp Epidemiol. 2003;24:86–96. [PubMed]
2. Siegel JD, Rhinehart E, Jackson M, Chiarello L the Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/hicpac/2007ip/2007isolationprecautions.html. [PubMed]
3. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service Guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. Atlanta, GA: US Department of Health and Human Services, CDC; 2013. Available at http://stacks.cdc.gov/view/cdc/20711. [PubMed]

Edward W. Hook M.D.
Edward W. Hook M.D.
31 months ago
Once again, you are seriously over-reading what you read.  For "instance, the most recent and up to date reference you cite is unreferenced and makes general statements including in reference no. 3 which states "Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they are visibly bloody"

My final answers to your follow-up questions are below, after which the thread will be closed and no further questions will be entertained.  If you wish to continue to believe you are at meaningful risk that is up to you.  We do not agree, based on our involvement in care and research on patients with and at risk for HIV since the epidemic began. 
1. No.
2.  No.
3.  Biologic survivability is not the same as infectivity and irrelevant to your concerns. 

End of thread.  EWH
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